LETTER TO A YOUNG PSYCHIATRIST
Vol 8 #4
Associate Clinical Professor, Psychiatrist, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA.
What made you decide to choose psychiatry? Besides the quality of life (schedule), the overlap with so many other fields (philosophy, psychology, neurology, sociology, the humanities), the continuation of a life of contemplation through literature or cinema, was it the possibility to also be a psychotherapist?
What was the appealing crusade that the young, and dedicated you wanted to partake in? Maybe you had a relative with psychosis and you became invested in finding a cure? Or maybe you lost a friend to suicide and wanted to dedicate your life to its prevention? Or maybe you were fascinated with the whole menu of anxiety disorders in the DSM and decided that you want to be a CBT expert? Or you love molecules and wanted to find the right antidotes for depression? Or addictions are your thing, and you felt like helping each alcoholic or drug addict reprogram their brain so they are no longer slave to the substance?
How many of you decided to become a psychiatrist to go on a crusade against trauma? I didn’t. When asked the question, “why are you applying to psychiatry?” I rather chose a vague answer: “to understand human beings”. Although this was true, behind this reason was another reason. My reasons were probably stacked like Russian dolls. But I just gave enough elements of the answer I thought would satisfy the interviewer, not more. It was easy to be pragmatic about an inner calling: I wanted to be a general adult psychiatrist because I loved medicine and would need to keep my differential diagnosis exhaustive. I was interested in alleviating human suffering and I wanted to be competent in treating most common mental disorders.
Deep down, I was also interested in contributing in the field of suicide prevention. I had heard of a cousin’s grandparent who had died by suicide. A few teachers (one of them had been among my favorite ones) and a janitor from my high school had also ended their lives, and one of my siblings’ classmates had shot himself. I found the latter especially disturbing since the boy was so joyful and funny to be around. What would lead someone to do this? I think suicide was even less taboo than trauma when I did my training, even though they can be interrelated (sexual trauma is a known risk factor for suicide). Plus, striving for social justice and healing trauma seemed at the core of psychiatry. Finding those two overlapping phenomena implicit, I didn’t anticipate having to speak this truth out loud.
As I now see it, many psychiatrists approach clinical practice like an aquarium, observing the fish and algae from the outside, not wanting to get wet. The thing is you are most likely all soaked already, or you are a fish that really needs to go back into the aquarium to survive… So eventually you will get wet…
The blind spot of medicine
During the early years after I graduated, I was fortunate enough to work in 3 different Canadian provinces before moving to the USA. Once in California, I worked in various settings where I could zoom in on even more social misery, yearning for the beloved and logical Canadian universal health care coverage. I also had two outpatient work experiences in Minnesota after that. Once there, I started noticing a disturbing pattern: many patients I would assess had been diagnosed with a severe mental illness. Since I was comprehensive in my assessments (the beauty of being a relatively fresh, non-jaded, open-minded early career psychiatrist) and asked a lot of questions, I found out frequent histories of abuse in childhood. I started identifying PTSD symptoms and saw a connection. The timing and symbolic meaning of the symptoms were striking: I will forever remember the story of this young man who generated my career-altering epiphany. He had been diagnosed with schizophrenia based on the hallucination of a bird… He was also married and a caring father. When asked about the beginning of the perceptual symptom, he disclosed that it was around the time a relative started sexually abusing him as a child. To me, this bird made perfect sense. It was a safe imaginary friend that emerged as he was going through the unnamable. The symptom was not pathological! It helped him cope. It told us something psychodynamically important about this patient. Maybe being a father had reactivated a fear that the same would happen to his own child? What was pathological was not the patient, but the past situation, the abuse he suffered, the perpetrator, and even, to a degree, the field that had failed to fully understand him. Gradually, as I listened to more stories, I discovered so many facets of dissociation.
I looked back at my rather solid 5-year residency training and started commiserating on the gap in knowledge about trauma-related conditions (PTSD was still associated mostly with military trauma or certain specific disasters). I had deep regrets about all the cases of trauma I had missed during all those years. Eventually I was making all kinds of connections. I wish I could turn back the clock. Even though I received my MD in 2000, the landmark ACE study that was published in 1998 was never mentioned in my medical school or residency years. Trauma had no specific place in the intake structure. It was like a hot potato that people eventually hid sometimes in the social and developmental history (because that part was sensitive and removed from the records when these had to be shared). As if it were a stain, or a big shame. Maintaining this taboo, this blind spot only created more problems, more splitting, more dissociation in our field.
I decided to order books on PTSD and self-educate on trauma. Then I moved back to California, worked with a different population. I was even more shocked that in a county system, people with so many diagnoses, other medical conditions and polypharmacy regimens were not asked about trauma (at least it was not documented in the chart; as it turned out, most notes from previous providers were useless). Maybe the exception was people who were refugees. But the vast majority had grown up in the USA and yet were presenting so many disabling symptoms that I started asking all my patients about trauma, even established ones. Many of them disclosed a history of abuse or neglect for the first time after decades.
To me this delay was unacceptable. I had to develop a bottom-up approach too, not just do damage control in the clinic where I worked supposedly at improving people’s lives. As an educator who started to create lectures for the institution I was affiliated with, I realized a course on such topics was non-existent in the residency curriculum. I was in a privileged position to develop it for residents. In parallel to being invested in my clinical and teaching roles, I saw some of my own reactions in a new light after patients who were survivors of attachment trauma or were victims of domestic violence reported similar ones: numbing, panic symptoms, depression, poor sense of self-worth, executive dysfunction. And there were too many possible diagnoses attached to each one of these core symptoms, generating an overwhelming plethora of labels. If I was experiencing some of this, maybe other physicians and trainees were too… Primary and/or secondary trauma are prevalent in our field. So an understanding will help all of us. I learned about myself by listening. I learned about human experience by observing my patients. They have been my best teachers. I became more self-aware because of them and in turn, was more effective in helping them due to my new insights. And in my intake note, years ago I made sure to add “ACEs and trauma” as the first item under “psychiatric history”.
In parallel to my patients’ healing journey, I also had to do my own. I decided to embrace my lived experience rather than seeing it as the constraint guiding my career choice, which had been the culmination of an unconscious re-enactment dictating a shift in the power dynamics between life and me that would allow me to triumph from adversity this time. It allowed me to abolish this “us-them” paradigm, especially when I realized quickly that the major difference between the patient and myself was my diploma (somewhere still in a box, not even hanging on the wall). I could have been sitting in that chair. In fact, I had. I am a wounded healer.
I am not asking you to like trauma or make it your passion. One of my children’s teachers told me “it takes a special kind of person to do that kind of work”. I think anyone who can access the necessary level of compassion can achieve that “specialness”. But until you figure out if you want to embark on that captivating journey, all I am asking you to do is to always rule it out. Rule out trauma, look for it or keep in mind that it might always lurk somewhere in a dark corner of a patient’s story. Assume that everyone one coming under your care has suffered some form of trauma or another until proven otherwise. Following universal “trauma precautions” has helped me to avoid causing more damage. Repair and healing can only occur when we are aware of the wounds so as to not repeat them.
-Many symptoms, especially in psychiatry, do not occur in a vacuum. Decode the symptom. Find the stressors. The problem becomes the solution.
-You cannot say a patient has no trauma. Even if the patient answers “no” to the question or even if the ACE questionnaire is negative. But we still ask, as it conveys the message that we care about this, and it helps in building trust, until the patient is ready to disclose.
-The majority of your patients will have experienced trauma. It is helpful to tell yourself that there is always trauma, until proven otherwise (and that can take a lifetime).
-It is possible to conclude that something happened to a patient yet the patient refuses to see it or call it trauma, but it clearly had an impact. Incorporate trauma into your understanding and come up with a common language that is less triggering or overwhelming for patients (“toxic stress” instead of “trauma”).
-The reality of trauma will be unavoidable in your career, even if you do only administration or very specific research. Some of the staff you’ll deal with might have suffered trauma, be triggered etc. Be as delicate with them as you would with a screaming infant.
-When approaching a patient in crisis, wonder if their reaction corresponds to any 4 Fs of the trauma responses (Fight, Flight, Freeze or Faint). This will guide your approach and make you potentially more responsive (using verbal de-escalation, validation, repair) rather than reactive (intramuscular medication, four-point immobilization, both of which can be retraumatizing).
-Being proactive is better than being flooded by an unexpected influx of traumatized patients in your panel. Be prepared to receive and respond to traumatic material. For instance, I always conclude an intake session or follow-up during which new material emerged by thanking my patients after they shared their story, which is an intimate part of their life. Such trust in us is a great gift and should never be taken for granted, especially since a perceived power differential from our role might trigger memories of oppression they have experienced from abusive institutions or people.
-I hope by now you are convinced that it is better to establish a foundation early on in your training or seek opportunities during trainings, continuous medical education, annual meetings, workshops, webinars, interprofessional discussions, reading clubs etc.
-One of the advantages of an emerging field is the numerous possibilities for discoveries, co-creativity and a dynamic career.
The more you accept that to look at this with the patient is part of your role, the better clinician you will be. In other words, avoidance will only make you and the patient waste time, and yes, life possibilities. Imagine a patient’s whose whole life was based on an erroneous diagnosis of a severe illness (I have countless such examples, which is very tragic), receiving ineffective treatments (of course), when in fact early identification of a trauma-related disorder would have led to appropriate treatments, empowerment and recovery? Misdiagnosis, retraumatization and polypharmacy are preventable.
The importance of context
The patients should guide the evolution of textbooks, not the reverse. In other words, if a patient doesn’t “fit’” a particular model or description, the tool is inaccurate, not the patient. Human experience cannot be completely conceptualized or categorized. To keep an open mind, I wish you to question everything, even seemingly competent colleagues’ former diagnoses of patients you are inheriting from them. Inevitably, you cannot get too attached to current, limited conceptualizations, especially the DSM. Many mental disorders or psychological syndromes reflect a specific historical context or structure. Think multidimensionally. Uncover agendas and potential conflict of interest in any expert, agency or institution claiming to hold the truth. To help you with that, learn about reference manuals’ history, authors’ background, potential biases at the time the book was written or updated, and relationships between the DSM task forces and the pharmaceutical industry. Diagnoses are just non-specific manifestations of the collision of life with people’s defense mechanisms and biological responses. Instead of using a checklist approach, look at what led to the diagnosis and address the blockade rather than relying on the “one symptom, one diagnosis, one pill” damaging approach. Psychiatrists are detectives. Symptoms are simply clues to help us understand a patient’s conflict. Learn to decode them. Using a holistic narrative that captures the patient’s conditions (rather than a list of codes), what led to them, and their resilience factors, will add context to the symptoms and will guide the therapeutic interventions.
The way the DSM is constructed prevents intersectional analysis and integration of fragments of disease in people. Fragmentation is contrary to fluidity and diversity. The DSM seems rooted in patriarchal structures. Patriarchy can be the common denominator of various individual and social problems throughout history such as racism, misogyny, trans-generational, institutional, gender-based trauma. As psychiatrists, we can help dismantle such fear-based structures and break the cycle of trauma by developing an awareness of the interconnection of systems of domination and oppression leading to a trauma legacy and retraumatization. By relying too much on the DSM, we run the risk of stigmatizing certain groups, oppressing them further. For instance, in the USA, people of color are more often diagnosed with severe mental disorders (such as psychosis) based on paranoia or agitation (often due to trauma and revictimization) as opposed to a more accurate diagnosis of PTSD. A diagnosis of PTSD better captures the pathogenesis underlying the emotional distress (societal trauma from ongoing racism, transgenerational trauma from slavery) and functional impairment. The condition is treatable and can have a better prognosis than schizophrenia. We have to dig for the meaning or the experience rather than relying on a criterion from a checklist. Symptoms are peripheral manifestations, not a deep understanding of a person’s complex mosaic including culture, socio-economic background, upbringing, attachment history, set of beliefs, sense of identity, defense mechanisms, biological vulnerabilities etc.
Sharing this knowledge with people we serve is enlightening and empowering. Throughout all this multidimensional and complex mission, bearing witness by listening to people stories has been the most rewarding aspect for me. As survivors are heard, they become whole again. Just being that presence for them is more powerful and has a more sustained effect than any pharmacological agent I know.
I chose to deepen my knowledge and understanding because it seems like trauma is the topic that chose me. If you pay attention, you will find that as a psychiatrist and as any specialist working with people for that matter, it has also chosen you. I trust that you will never get bored. Vicarious resilience keeps me going and learning. Think of what inspires you about a particular patient’s difficult story and it will boost your resilience.
Thank you for following me through my rather long epistolary storytelling. I could go on and on, believe me. Maybe you will join in a dialogue with me some day. Good luck in this journey full of possibilities to improve our world by helping survivors of trauma to heal, the most courageous people I have ever met.